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Waste Tire Survey & Inspection Report Inspection Report Number � <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 9 1 9- 1 41 31 32 <br /> California Integrated Waste Management Board <br /> PartA-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- y� Inspection Type (Fill one) <br /> Site Suffix: 3 Z Z 9 CJ <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral <br /> Identifier: �� I type(Fill one) <br /> y. Ogg r� Ty r�N� IQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phys l al Address F <br /> �'A Inspection Date <br /> i Time In Time Out <br /> Business Rep Title , <br /> �AM Q AM <br /> O PM Q PM <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _- Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O O Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet QGovemment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ll <br /> WA <br /> F V <br /> w- - <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR 1845 - <br /> Q Q § 9 Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB :w <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ,1, <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ? R <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators =�, =,. <br /> Q Q 1 Other: § x _ <br /> Comments <br /> I •.tY�i S J <br /> Inspection Form Included:Q q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number or's Si re Phone Number <br /> !° _ <br /> ■ INSTRUCTIONS ON BACK E X A P,L E 62081 <br /> N <br /> 1 . <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> L17 11G44.Cl116 <br />